CQC report explained · a residential care home
What the CQC found at Roman Wharf Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People said they felt safe. Risks, safeguarding concerns, medicines, staffing, recruitment and infection control were managed appropriately.
- Effective?
- Good
- People's health, nutrition and hydration needs were supported. Staff had up-to-date training and followed guidance about consent and decision-making.
- Caring?
- Good
- Staff treated people with respect and protected their privacy and dignity. People and relatives were involved in care decisions.
- Responsive?
- Good
- Care plans were personalised and staff understood people's needs and preferences. Activities, communication support, family contact and complaints processes were in place.
- Well-led?
- Requires improvement
- Quality monitoring had improved, but the home had a history of inconsistent leadership and ineffective checks. Inspectors wanted to see the improvements sustained over a longer period.
What inspectors found, March 2024
Rated Good and no longer in Special Measures; inspectors found safe, kind care but said quality checks must be sustained.
This was an unannounced follow-up inspection on 25 and 26 July 2023. Inspectors spoke with people, relatives, staff, managers and a health professional. They observed care and reviewed care records, risk assessments, monitoring information and staff files.
The home was rated Good overall. Safe, effective, caring and responsive were all rated Good. Inspectors found people felt safe, received their medicines properly, had their health and nutrition needs supported, and were treated with dignity and respect.
Well-led was rated Requires Improvement. The manager had improved quality checks, care plans and medicines monitoring, but had only been in post about four months. Inspectors wanted to see these improvements continue for longer, especially as only 18 of the home's 50 places were occupied.
The home had previously been rated Inadequate and had been in Special Measures since July 2022. Inspectors found improvements and said the home was no longer in breach of regulations or in Special Measures.
People felt safe
People said they felt safe and trusted the staff. Safeguarding concerns were investigated and staff understood how to raise concerns.
“People told us they felt safe at the service.” from the report
Risks were managed
Care plans and risk assessments were up to date. Inspectors found suitable measures for falls, skin damage, bedrails and emergency evacuation.
“The risks to people's safety were well managed.” from the report
Kind and respectful care
Staff supported people's dignity, privacy, independence and choices. Inspectors saw positive engagement between staff and people.
“We saw positive engagement with people from all staff working at the service.” from the report
Quality checks need to last
needs fixingThe manager had improved monitoring systems, but inspectors were not yet confident that these improvements would continue. The home had only 18 people living there at the time, compared with 50 registered places.
“We would need to see the improvement in quality monitoring processes seen at this inspection, sustained over a longer period of time to be assured good outcomes for people would be maintained.” from the report
Manager not yet registered
minorThere was no registered manager in post during the inspection. The manager was going through the registration process.
“At the time of our inspection there was not a registered manager in post.” from the report
- 01How are you making sure the improved quality monitoring continues as the number of people living here changes?
- 02Has the manager completed the registration process, and who is responsible for the home until then?
- 03What checks are carried out on medicines, and how are any errors followed up?
- 04How are care plans reviewed with each person and their relatives?
- 05How do you make sure staffing levels remain safe when there are staff shortages?
This was an unannounced follow-up inspection covering all five key questions, including care, records, staffing, medicines, the environment and infection control. This explanation was written from the published report of 26 March 2024 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, May 2023
Rated Inadequate and remains in special measures; inspectors found serious safety and leadership failures despite some kind care and ongoing improvement work.
This was an unannounced comprehensive inspection. Inspectors visited on 18 and 23 January 2023, and reviewed information until 3 February 2023. They spoke with people, relatives, staff, managers and a safeguarding professional. They also observed care and checked care records, risk assessments and staff files.
The home remained rated Inadequate overall. Safe and well-led were Inadequate. Effective, caring and responsive were Requires Improvement. Inspectors found that concerns from the previous inspection had not improved enough.
People were at risk because abuse and accidents were not always reported or investigated, risks were not always managed, medical advice was not always followed, and medicines records and storage were not always safe. Staff training, supervision, mental capacity assessments and quality checks were also not consistently effective.
There were some positive findings. People said staff were kind, felt safe and were generally positive about the food. Staffing levels were considered safe, complaints were acted on, relationships were supported and end of life wishes were recorded. However, the home remains under review and will be re-inspected.
Kind staff
People and relatives said staff were kind and caring. Inspectors also saw examples of staff helping people and relatives.
“People told us staff were kind and caring and got to know them well.” from the report
Staffing levels
Inspectors observed call bells being answered promptly and found staffing levels were safe. Most people said there were enough staff.
“Staffing levels were safe, and people told us they felt safe.” from the report
Food and relationships
People and relatives were generally positive about the food. The home also supported people to keep in touch with relatives.
“People and relatives were generally positive about the quality and choice of food provided.” from the report
Complaints handled
People knew how to complain, and inspectors saw records showing that complaints had been acted on.
“We saw recorded evidence of people's complaints and these concerns being acted upon.” from the report
Healthcare partnership
The manager and staff took part in regular meetings with healthcare professionals and supported people to access healthcare.
“The manager or staff took part in frequent multi-disciplinary meetings with local healthcare professionals to raise any concerns about people's care and support.” from the report
Safeguarding failures
seriousSeveral alleged abuse incidents were not recorded, reported to the manager or referred to the local safeguarding authority. This meant people were not consistently protected from abuse or the risk of abuse.
“Multiple incidents of alleged self-neglect, physical and verbal abuse had not been recorded in relevant incident forms by staff and had not been reported to the manager.” from the report
Falls and risk management
seriousThree falls, including two with injuries, were not recorded in the correct forms. Medical advice for hourly checks after a head injury was not followed.
“Records showed the provider failed to ensure these checks were carried out to monitor the person's wellbeing and keep them safe.” from the report
Medicines safety
seriousMedicines were not always stored and documented safely. Advice from the pharmacy had not been obtained before one person's medicines were given covertly.
“Medicines administration, storage and documentation was not always safe.” from the report
Staff training and supervision
seriousStaff had missed important training, induction records were incomplete and most staff had not received supervision or appraisals as required.
“The provider had failed to ensure staff received appropriate support, training and supervision.” from the report
Poor quality monitoring
seriousThe home's systems did not reliably identify or respond to risks. Repositioning was not always recorded, and accident and incident information was incomplete.
“Quality monitoring systems were not effective.” from the report
Personalised support
needs fixingLife histories and dementia-friendly signs were not always available. Some care language was not respectful, and activities were limited when the activity co-ordinator was away.
“People's life histories were not always documented.” from the report
- 01What has changed to make sure every allegation of abuse is recorded, investigated and referred to the safeguarding authority when needed?
- 02How do you now record falls and other incidents, check that medical advice is followed, and make sure lessons are learned?
- 03How are medicines, including any covert medicines, checked with the pharmacy, stored and recorded safely?
- 04What training, induction, supervision and appraisal will staff have before caring for my relative?
- 05How will you provide personalised activities, life-history information and dementia-friendly signage when the activity co-ordinator is absent?
This was an unannounced comprehensive follow-up inspection covering all five key questions and infection prevention and control, after the previous Inadequate rating and Warning Notice. This explanation was written from the published report of 27 May 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Roman Wharf Care Home
5 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- March 2024Goodcurrent ratingup from InadequateSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2023Inadequatestayed InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- October 2022Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- February 2021Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- October 2019Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- March 2021
Registered with the Care Quality Commission on 22 March 2021.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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9 live-in carers within about an hour of Lincolnshire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
8 can care for a couple. 10 years' experience on average.
“Martin was more than a carer, he managed the home and became my uncle's best friend, enriching his life during his last few years.”
“Magda was always positive and proactive about trying new things to keep dad busy. She also introduced new ideas for keeping dad healthy.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.